Intra Uterine Device (IUD) - Consent Form

This consent form is to help you decide and confirm your consent to proceed with the insertion of an intrauterine device (IUD) and if needed, the use of a local anaesthetic.

I am having a:

and it will stay in for:

The nature of the procedure has been fully explained to me and I have been supplied with information (click on button) on this method of contraception.

I understand the IUD has risks and by clicking this check box I confirm I have read, understood and discussed the side effects and risks with my doctor. *

Information on IUD

Hormone Releasing IUD

Failure of the IUD to prevent pregnancy and the increased chance of ectopic pregnancy if the method fails
Expulsion (pushing out) of the IUD
Pelvic infection (infection of the uterus and tubes)
Perforation (travel through the walls) of the uterus by the IUD requiring referral to a gynaecologist for removal by laparoscopy
Changes of the menstrual cycle and menstrual bleeding pattern

Please confirm your undertanding of the following by clicking each box in turn.

I understand it is my responsibility to make an appointment for removal or replacement at or before that time *

I am aware of the ongoing care I will need to take while using the IUD and the importance of attending my follow up appointment. *

I have given information regarding my menstrual cycle and contraceptive use that allows the doctor to assess that I am not pregnant at the time of IUD insertion. *

I understand that should clinical or anatomical difficulties prevent the insertion of the device, or should the device be expelled prior to its usual life-span, I will be responsible for the cost of the device. *

First Name *

Last Name *

Please enter your date of birth *

Today's Date

Signature

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Today's date

DoctorsSignature

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Doctor